Test Bank For Prioritization, Delegation, and Assignment, 5th Edition, Practice Exercises for the NCLEX Examination Updated, All Chapters 1-22.
Test Bank For Prioritization, Delegation, and Assignment, 5th Edition, Practice Exercises for the NCLEX Examination Updated, All Chapters 1-22
Test Bank For Prioritization, Delegation, and Assignment, 5th Edition, Practice Exercises for the NCLEX Examination Updated, All Chapters 1-22 ||Complete A+ Guide
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Nursing Prioritization, Delegation, Assignment
1. Question
A 16-year old patient with cystic fibrosis is admitted with increased shortness of
breath and possible pneumonia. Which nursing activity is most important to
include in the patient’s care?
Perform postural drainage and chest physiotherapy every 4 hours.
Airway clearance techniques are critical for patients with cystic fibrosis and
should take priority over other activities. The Cystic Fibrosis Transmembrane
Conductance Regulator defect causes mucus to become dehydrated. Secretions
in cystic fibrosis are generally thick, sticky, and more difficult to clear. Frequent
airway clearance is a mainstay in the treatment of acute exacerbations, as well
as an integral part of health maintenance in cystic fibrosis.
2. Question
A patient with a pulmonary embolism is receiving anticoagulation with IV
heparin. What instructions would you give the nursing assistant who will help
the patient with activities of daily living?
✓ Risk for bleeding may arise in any condition that disturbs the “close
circuit” integrity of the circulatory system. Bleeding is the primary
complication of anticoagulant therapy and is a risk of all anticoagulants
even when maintained within the usual therapeutic ranges.
✓ Educate the at-risk patient about precautionary measures to prevent tissue
trauma or disruption of the normal clotting mechanisms. Information
about precautionary measures lessens the risk for bleeding.
✓ Be careful when using sharp objects like scissors and knives. Use an
electric razor for shaving (not razor blades). The patient needs to avoid
situations that may cause tissue trauma and increase the risk for bleeding.
✓ Use a soft-bristled toothbrush and nonabrasive toothpaste. Avoid the use
of toothpicks and dental floss. This method providing oral hygiene
reduces trauma to oral mucous membranes and the risk for bleeding from
the gums.
, ✓ Educate the patient and family members about signs of bleeding that need
to be reported to a health care provider. Early evaluation and treatment of
bleeding by a health care provider reduces the risk for complications from
blood loss.
3. Question
A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen
by a non-rebreather mask, but arterial blood gas measurements still show poor
oxygenation. As the nurse responsible for this patient’s care, you would
anticipate a physician order for what action?
Perform endotracheal intubation and initiate mechanical ventilation
A non-rebreather mask can deliver nearly 100% oxygen. When the patient’s
oxygenation status does not improve adequately in response to the delivery of
oxygen at this high concentration, refractory hypoxemia is present. Usually, at
this stage, the patient is working very hard to breathe and may go into
respiratory arrest unless healthcare care providers intervene by providing
intubation and mechanical ventilation to decrease the patient’s work of
breathing.
4. Question
A patient with chronic obstructive pulmonary disease (COPD). Which
intervention for airway management should you delegate to a nursing assistant?
Assisting the patient to sit up on the side of the bed.
Assisting patients with positioning and activities of daily living is within the
educational preparation and scope of practice of a nursing assistant. Some
examples of tasks and aspects of care that can be delegated legally to
nonprofessional, unlicensed assistive nursing personnel, provided they are
competent in these areas, under the direct supervision of the nurse include
assistance with transfers, range of motion, feeding, ambulation, and other tasks
such as making beds and assisting with bowel and bladder functions.
5. Question
A patient with sleep apnea has a nursing diagnosis of Sleep Deprivation related
to disrupted sleep cycle. Which action should you delegate to the nursing
assistant?
Remind the patient to sleep on his side instead of his back.
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